OBSERVATIONAL LEARNING REQUEST FORM
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1 OBSERVATIONAL LEARNING REQUEST FORM Thank you for your interest in the observational learning/shadow experience at University Hospitals Portage Medical Center. Currently, shadowing is available in a variety of healthcare career areas. Volunteer Services will try to accommodate your request, although placement cannot be guaranteed. Observational experiences are typically limited to a maximum of 4 hours. Please be aware that for physician, physician assistant and nurse practitioner shadows, the observer will be required to contact and arrange their shadow experience independently but all other steps of the process must be followed. STEPS TO APPLY: 1. To begin the process, complete the Observational Learning Request Form so that we can place you appropriately. Requests must be received at least 2 weeks prior to a requested date. Once the completed forms are received, you will be contacted by Volunteer Services to confirm the date and appropriate department for your observational learning experience. 2. If you are shadowing during flu season months (typically November through March) you will need to attach proof that you have received a flu vaccination for the season. You will NOT be allowed to shadow if you do not bring proper documentation (vaccine record receipt from drug store or physician documentation). 3. On the day of your shadowing experience, please report to Volunteer Services 15 minutes before your scheduled time. You will receive a Visitor Badge and be escorted to your assigned area. Lunch is available in the cafeteria at the observer s expense. 4. Following your shadow experience, please return your Visitor Badge and the attached Observational Learning Completion Form to the Volunteer Services office. Please return items to: Volunteer Services, UH Portage Medical Center 6847 North Chestnut Street, Ravenna, Ohio Dress Code and Personal Appearance: Shadow students are expected to dress appropriately for their experience; solid color dress or khaki style pants, dress shirt, and clean and comfortable closed-toed shoes. Please do not wear denim jeans, capris, shorts, sleeveless blouses, sandals, or any attire that shows undergarments.
2 OBSERVATIONAL LEARNING REQUEST FORM PERSONAL INFORMATION First Name Last Name Address City State Zip Phone Number ( ) High School Student College Student Adult Learner SCHOOL INFORMATION Currently Attending Major Current school status: Freshman Sophomore Junior Senior Graduate Out of School EMERGENCY CONTACT INFORMATION Name Phone Number ( REQUEST ) If you have already arranged a job shadow with a UH Portage Medical Center employee or department, please list their contact information below. Employee Name: Job Title: Department: Date/Time Arranged : What job (s) or occupation(s) are you interested in observing. List choices in priority order. 1 st choice: 2 nd choice: 3 rd choice: What date or day of the week do you prefer to do the observation? / / *A 2 week notice is required BEFORE your desired shadow experience* What days of the week are you available to shadow? Monday Saturday Tuesday Sunday Wednesday Thursday Friday What time are you available for an observation? Between 8-noon Between 1-5pm Other *Shadowing is limited to a maximum of 4 hours* or week of *Saturday & Sunday shadows are not available in many departments* For Office Use Only Contact Person Contact Info Department Date Time Student Badge Computer Check
3 OBSERVATIONAL LEARNING RULES AND PROCEDURES Shadowing in a hospital is different in many ways compared to other job shadowing experiences. Listed below are important things to keep in mind while you are here. If you have any questions, please ask your contact person, the supervisor of the department in which you are shadowing or the Volunteer Services staff. Please read, check each box, sign the back and return with the Observational Learning Request Form to the Volunteer Office. Patient Rights/Confidentiality: Persons seeking services at UH Portage Medical Center have the right to have all information about their visits remain confidential. That means you cannot share information about any patient. You cannot tell anyone that a person is or is not a patient. Remember, what you see and hear stays here. Patients also have the right to privacy. Please be respectful and offer privacy if the situation arises. Smoking: UH Portage Medical Center is a non-smoking facility. Smoking is not allowed on hospital grounds, including the parking lots. Cell Phones: Cell phones are not permitted to be used during your shadow experience. Phones/purses can be stored in lockers in the Volunteer office. Emergency Pages: You may hear different overhead codes while at UH Portage Medical Center. Do not be alarmed. The overhead pages and explanations are listed below: Code Red: Fire Code Adam: Infant/Child Abduction Code Black: Bomb/Bomb Threat Code Gray: Tornado/Severe Weather Threat Code Orange: Hazardous Material Spill/Release Code Blue: Medical Emergency- Adult and Pediatric Code Pink: Medical Emergency- Infant Code Yellow: Disaster Code Violet: Violent Person Code Silver: Person with Weapon, Hostage Situation Code Brown: Missing Adult Patient During a Code Red, double doors located throughout the hallways of the hospital will automatically close. No one should go through a closed smoke door until an all clear message is announced by overhead announcement. Do not use the telephones. Tornado Warning- You should go to the innermost part of the building on the lowest floor and stay away from windows. Do not use elevators because the power may fail, leaving you trapped.
4 OBSERVATIONAL LEARNING RULES AND PROCEDURES Personal Safety: UH Portage Medical Center employees and visitors enjoy a relatively safe environment. Because this is a public area, we would like you to be aware of personal safety concerns. Do not park in handicapped designated areas. Police and Protective Service staff are available to walk you to your car after dark. Store purses and other valuables in designated areas. Wear your special identification badge at all times while you are in the building. Infection Control: Please be aware that a hospital serves both those individuals who may have an infection (e.g. tuberculosis) and people at risk to pick up infections (e.g. a newborn baby or person being treated for cancer). For these reasons, we request that you practice basic infection control procedures. You should wash your hands frequently while in the hospital. Hand washing is the single most important thing you can do to prevent the spread of infection. You should wash your hands at the following times: As you enter and leave the building Before you handle food Between any patient contact After using the restroom After coughing or sneezing Please observe the signs on patient rooms. DO NOT enter a patient room with an infection control warning sign. If you see a sharp object, DO NOT attempt to pick it up; notify an employee to pick up a sharp object. If you are ill, please stay at home. Notify Volunteer Services at (330) Hazardous Materials: Some areas of the hospital use chemical or radioactive materials. Please observe any department s specific instructions. DO NOT enter any rooms with the radioactivity symbol sign on the door.
5 OBSERVATIONAL LEARNING AGREEMENT APPLICANT AGREEMENT I have read the Student Observational Learning Experience forms for UH Portage Medical Center and hereby certify that all information provided in this request is accurate. I understand that submission of this request does not guarantee placement and is at the discretion of UH Portage Medical Center. I also understand that documentation of receiving a flu vaccination during specified months is required for shadowing. Further, I understand that an observational learning experience is strictly observation (no hands-on learning or clinical care will be provided). As an observational learner I am required to be with my preceptor at all times. Printed Name Date Applicant Signature
6 Observational Learning Completion Form Please complete this form and return it to Volunteer Services upon completion of your shadow hours along with your hospital issued Visitor badge. Observer Name: School: Observation Date(s): Major: Total Hours Observed: Preceptor Name: Position: Department of observation: Preceptor Signature: Please rate your shadow experience on a scale of 1 (poor learning experience) to 10 (excellent learning experience): What is something new that you learned from this experience?
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